Dent 356-13

Diseases of the Temporomandibular Joint

Developmental Disorders Developmental Disorders
Inflammatory Disorders Inflammatory Disorders Inflammatory Disorders Inflammatory Disorders
Osteoarthrosis Osteoarthrosis
Functional Disorders* Functional Disorders*
Loose Bodies Loose Bodies
Neoplasms Neoplasms
Age Changes in the Jaws & TMJ Age Changes in the Jaws & TMJ
Trismus Trismus & Dislocation & Dislocation
*To be covered in oral medicine courses. *To be covered in oral medicine courses.
Developmental Disorders:
Condylar Aplasia
Extremely rare.
May be unilateral or
bilateral. bilateral.
Most reported cases
associated with other facial
anomalies.
Developmental Disorders: Condylar Hypoplasia
Congenital: unknown causes, unilateral or bilateral.
Acquired: trauma (birth injury or fracture), radiation, or infection,
usually extending from middle ear.
The earlier the damage, the more severe the resulting facial
deformity. deformity.
Developmental Disorders: Condylar Hyperplasia
Rare, self-limiting, of unknown cause.
Generally unilateral; facial asymmetry and deviation of mandible to
opposite side and malocclusion.
Becomes apparent during 2
nd
decade of life. Becomes apparent during 2 decade of life.
Inflammatory Disorders: Traumatic Arthritis
Damage to joint following
acute trauma may lead to
traumatic arthritis or
hemarthrosis.
Usually resolves if tissue Usually resolves if tissue
damage is not severe.
Otherwise, scar tissue
formation may lead to
ankylosis.
Inflammatory Disorders: Infective Arthritis
Rare.
Infection may reach TMJ by:
1. Direct spread from adjacent focus, e.g. middle ear
or surrounding cellulitis.
2. Hematogenous spread from distant focus.
3. Facial trauma.
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Staphylococcus aureus most common isolate, TMJ
may be part of infective polyarthritis, e.g.
gonococcal or viral arthritis.
Pain, trismus, deviation on opening, signs of acute
infection.
May result in fibrous or bony ankylosis.
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Inflammatory Disorders: Rheumatoid Arthritis
Non-organ specific autoimmune
disease with articular and extra-
articular manifestations.
Commonly begins in early adult life,
more frequently in females.
Systemic distribution in which joint Systemic distribution in which joint
involvement is the main feature.
Other features include anemia, weight
loss, and subcutaneous nodules over
bony prominences and joints.
10% of patients may show features of
Sjgren syndrome.
Inflammatory Disorders: Rheumatoid Arthritis
Smaller joints are usually affected, particularly in the hand.
Distribution tends to be symmetrical.
TMJs involved in 20-70% of cases, although few complain of TMJ pain.
When symptomatic, TMJ involvement presents as: When symptomatic, TMJ involvement presents as:
Limitation of opening (trismus).
Stiffness.
Crepitus.
Referred pain.
Tenderness on biting.
Severe disability is unusual.
Inflammatory Disorders: Rheumatoid Arthritis
Joint involvement starts as
synovitis with intense
infiltration of lymphocytes
and plasma cells.
Inflamed synovial tissues
proliferate and synovial
membrane becomes
hyperplastic.
Inflammatory Disorders: Rheumatoid Arthritis
Synovial membrane forms folds which extend over articular surfaces, clothing
them in a vascular pannus.
Inflammatory Disorders: Rheumatoid Arthritis
The pannus causes resorption of
articular surfaces, which may
extend into adjacent bone.
Articular surfaces may become very
irregular and fibrous ankylosis may
Articular surfaces may become very
irregular and fibrous ankylosis may
result, either in the lower joint
compartment or with total
destruction of articular disc and
complete ankylosis.
Inflammatory Disorders: Rheumatoid Arthritis
Serological findings:
Presence of rheumatoid factor (RF) in 85% of patients.
RF: an IgM-class autoantibody against chemical groups on IgG molecules.
Its significance in RA and other CT diseases is unknown, but immune-
complex deposition may be the mechanism involved.
Elevated ESR because of hypergammaglobulinemia.
Osteoarthrosis (Osteoarthritis)
A degenerative disease which mainly affects weight-bearing joints.
In the TMJ, it differs from other joints probably because:
1. It is not a weight-bearing joint.
2. The articular surface is covered with fibrous tissue rather than hyaline
cartilage. cartilage.
It is rare in TMJ before 5
th
decade of life, but after that it increases
proportionately with age.
Osteoarthrosis
Clinical features:
Pain.
Crepitus.
Limitation of jaw movement.
Deviation on opening.
Many cases are clinically silent. Clinical studies suggest a relationship in some cases
between later development of osteoarthrosis and:
a. untreated myofascial pain-dysfunction syndrome,
b. loss of molar support,
c. disc displacement.
Spontaneous resolution is common.
Osteoarthrosis
Histological changes:
Early changes consist of uneven
distribution of cells in articular
covering of condyle +/- some
osteoclastic resorption of
subarticular bone.
osteoclastic resorption of
subarticular bone.
Vertical splits (fibrillation)
develop in articular layer.
Followed by fragmentation and
loss of articular surface with
eventual denudation of
underlying bone.
Osteoarthrosis
Histological changes:
Reactive changes in exposed bone
lead to thickening of trabeculae and
formation of a dense surface layer-
eburnation.
Osteophyte (bony spur) formation
may occur on anterior surface as an
reaction by underlying bone to
repair damaged articular cartilage.
There may be eventual perforation
of the articular disc.
Osteoarthrosis
Radiographic changes:
Variable and not pathognomonic.
Focal or diffuse areas of bone loss on
articular surface of condyle.
Flattening and reduction in total bony
size of condyle.
Reduction in joint space. Osteophytes
may be seen at anterior edge of
condyle.
If large, they may fracture off and
present on radiographs as loose
bodies.
Osteoarthrosis
Osteoarthrosis
Loose Bodies
Radiopaque bodies apparently lying
free within the joint space are
common in major joints but rare in
TMJ.
They may cause discomfort, crepitus,
and limitation of movement. and limitation of movement.
The main causes in TMJ are:
1. Intracapsular fractures.
2. Fractured osteophytes in
osteoarthrosis.
3. Synovial chondromatosis.
Loose Bodies
Synovial Chondromatosis:
disease of unknown etiology
characterized by formation of
multiple nodules of cartilage
which may calcify and ossify,
scattered throughout the scattered throughout the
synovium.
They may be released in the joint
space and appear as loose
bodies.
Neoplsams
Primary neoplasms of the
TMJ are rare.
Benign tumors such as Benign tumors such as
chondromas and osteomas
are more frequent than
sarcomas arising from bone
or synovial tissues.
Age Changes in the Jaws & TMJ
Atrophy of alveolar bone is
mainly related to tooth loss.
Its extent increases with age, and
is probably accelerated by
osteoporosis.
It results in loss of facial height,
upwards and forwards posturing
of the mandible, especially in the
absence of dentures.
Age Changes in the Jaws & TMJ
In the TMJs, it is difficult to distinguish
changes due to ageing from those related to
osteoarthrosis.
The main changes are related to remodeling
of the articular surfaces and disc in response
to functional changes following tooth loss.
Remodeling may result in anterior
displacement of the disc.
There may be perforation of the disc,
particularly of its posterior attachment with
progressive joint damage and osteoarthrosis.
TMJ disc with perforation
http://www.srt-
psc.com/4case99.html
Trismus and Dislocation
Trismus: limitation of
movement.
In the TMJ, temporary
trismus is more common
than permanent trismus.
trismus is more common
than permanent trismus.
Trismus may be caused by
intra-articular or extra-
articular factors.
Causes of Trismus
Intra-articular:
Traumatic arthritis
Infective arthritis
Rheumatid arthritis
Dislocation
Intracapsular fracture
Fibrous or bony ankylosis following trauma or infection
Causes of Trismus
Extra-articular:
Adjacent infection, inflammation, and
abscesses (e.g. mumps, pericoronitis,
submasseteric abscess)
Extracapsular fractures (mandible, zygoma,
middle 3
rd
)
Overgrowth (neoplasia) of the coronoid
process
Fibrosis from burns or irradiation Fibrosis from burns or irradiation
Hematoma/ fibrosis of medial pterygoid (e.g.
following inferior dental block)
Myofascial pain-dysfunction syndrome
Drug-associated dyskinesia & psychotic
disturbances
Tetanus
Tetany
Mandibular subcondylar fracture
http://emedicine.medscape.com/article/
870075-overview#aw2aab6b5
Dislocation
Dislocation of the TMJ is uncommon.
Displacement of the condyle out of the glenoid fossa beyond
the articular eminence.
Causes of unstable joint:
1. Abnormal neuromuscular activity.
2. Weakness of capsule and lateral ligament.
3. Anatomical factors related to contour of glenoid fossa or disc.
Rarely, in some patients, dislocation may be recurrent or
habitual.
THE END